Should PPO Fees Or Full Fees Be Reported On Claims?

While it may be easier to bill the PPO fee when submitting claims, this is not wise from a business management point of view. The ADA encourages dentists to bill their full fees on all dental claims and take contracted write-offs after the claims have been paid — and so do I.

Here are the reasons why you should submit your full fee:

Sometimes a PPO plan will raise its allowable fees.If the plan fails to notify contracted providers of this increase, the provider will be paid its reported fee. Billing your full fee will ensure that the practice receives the highest PPO fee available on that service date.

Most large dental insurance carriers monitor the fees submitted on dental claims submitted for payment.The carriers analyze those fees submitted to help establish “UCR” fees for the participating doctors in a given market. If you always bill your contracted fee rather than your full fee, you bring down the “average” fee in your market area.

Some secondary payers are required by contract law or state lawto coordinate up to their allowable fee if it is higher than the primary dental plan’s allowable fee. However, the secondary plan will never coordinate up to a higher fee than you charge on the claim form. If you charge your full fees, you may find that some secondary plans will co-ordinate payment up to the practice’s charges. Thus, under some scenarios with two or more plans, the secondary payment results in the practice receiving its full charges— in spite of the low fee schedule of each PPO.

From a management perspective, it is essential to be able to perform an “apples to apples” comparison of PPO networks to determine which ones are better than others. This involves not only comparing fees, but also monitoring how a carrier’s processing policies trigger write-offs. Reporting full fees on claims and analyzing the total write-offs compared to total charges for each PPO network allows a dentist to understand the true costs and benefits of participating in each network. PPO plans now represent approximately 77% of the dental benefits market and continue to grow. 85% of dentists participate in one or more plans. Dentists should evaluate their write-offs periodically and determine the benefits/risks of continued participation in less profitable PPO networks with burdensome administrative constraints. Eliminating those less-profitable plans may help to accommodate patients from more profitable PPO networks.

As the number of patients covered by PPO plans increases, reimbursement becomes more restricted. With insurance administration complicated by more and more complex restrictions and limitations, business staff must be given the training and coding tools necessary to maximize legitimate reimbursement for its patients. Without adequate tools and training, what is the end result? Money is left on the table, something that no practice wants or needs.

The bottom line: Always submit your full fees and only post write-offs after all payments have been received.